Exam 1 (Ethics, Quality Control, Leaders vs Managers, Conflict Resolution, Delegation)

moral distress

negative emotional response when you know the morally correct action but are prevented from taking it

moral residue

lingering feelings after moral distress has been resolved

ethical dilemma

conflict between 2+ ethical principles with no "correct" decision

what makes a problem an ethical dilemma?

-inability to be resolved w/ review of scientific data

-creates conflict b/w ethical principles

-answer has a profound effect on the situation/patient

ethical principles of nursing

autonomy, beneficence, nonmaleficence, justice, veracity, confidentiality, fidelity, paternalism

autonomy

-personal freedom, the right to choose

-ex: informed consent, progressive discipline, staff decisions on patient care

beneficence

-take actions for the best good for the patient

-ex: treat w/ respect, patient interest = primary concern, manage pain, be certified and knowledgeable

non-maleficence

-do no harm

-ex: actions that minimize errors and max patient safety, only perform treatment when benefit outweighs the burden, refuse to provide a treatment if it's been proven to be dangerous, correct dosing errors/orders, notify PCP of abnormal findings

justice

-treat everyone w/ fairness, equally, without prejudice

-ex: stewardship of resources, make schedule fairly

veracity

-truth telling at all times

-ex: tell patient and family of mistakes, report suspected impaired colleagues

paternalism

-allowing a person to make a decision for another, overriding autonomy due to beneficence

-can be good, can be bad

-ex: mandatory flu vaccines

fidelity

-loyalty, faithfulness, advocacy, dedication

-ex: keep your promises, fulfill commitments

respect for others

highest ethical principle, acknowledging inherent, intrinsic, and unconditional worth of everyone

confidentiality

-right to privacy

-exceptions in employee substance abuse, abuse of elderly/children, when HIPPA authorized

steps in ethical decision-making

-ID if the issue is an ethical dilemma (assessment)

-state ethical dilemma, including all surrounding issues and individuals (diagnosis)

-list and analyze possible solutions and review the implications (plan)

-select option that is in concert with the applicable ethical principle, the decision maker's beliefs, the professional values for patient care, and justify why that one was selected (also plan)

-apply decision to dilemma and evaluate (implement and evaluate)

medical ethics committees

-group of inter-professional providers who provide guidance and structure to assist with ethical decision-making

-any healthcare provider can refer a situation to the committee

leadership in ethics

foster ethical work environments, seek counsel when necessary, promote moral courage (both self and others), provide mutual staff support, educate staff and self, mentor future leaders (ethical succession planning)

advocacy

-one of the most important roles as both a nurse and leader

-ensures safe work environment, conducive to professional and personal growth

skills of advocacy

risk taking, vision, self-confidence, articulate, communication, assertiveness (but don't be a dick)

ethical climate

-organizational environment in which ethical implications are ID, discussed, and decided upon

-embodies the character of the organization and should be changed if needed

characteristics of exemplary ethical organizations

recognize activities that influence ethical care, lead by example, establish ability to monitor ethics, involve key members of IDing and managing values (think written code of conduct), disseminate understanding of values to staff, seeks to ID threats and conflicts among values

STEEEP (6 aims for heathcare quality)

safe; avoiding injuries to patients from the care intended to help

timely; reducing wants or potentially harmful delays for patients AND providers

effective; providing appropriate level of services based on scientific knowledge

efficient; avoid waste of equipment, supplies, ideas, and energy

equitable; provide care that does not vary in quality based on personal bias

patient-centered; care that is respectful and responsive to individual patients

2025 hospital safety goals from JCO

ID patients correctly, improve staff communication, use medicine safely, use alarms safely, prevent infection, ID patient safety risks, improve healthcare equity, prevent surgical mistakes

healthcare quality

degree to which health services for individuals and populations increase the likelihood of desired health outcomes, and are consistent with current professional knowledge

quality improvement

use of data to monitor the outcomes of care processes and use improvement methods to design and test changes in order to continuously improve the quality and safety of healthcare systems

characteristics of quality improvement

systematic process to improve outcomes, based on patient needs, proactive, is responsibility of ALL

quality improvement vs quality assurance

improvement; systematic process, continuous, prospective, responsibility of all

assurance; inspection approach, retrospective, responsibility of few

structural indications of quality

available staffing, infection control, skill mix, education of staff, resources, supplies, budget, layout of unit

process indications of quality

evidence-based guidelines, use of nursing process, standards of care, policies and pathways, core measures, care routines, frequency of assessments

outcome indicators of quality

incidence of CAUTI/pressure ulcers, medication errors, falls, patient satisfaction rates

steps to quality improvement

-ID problem/chance for improvement

-ID metric associated w/ problem

-examine historical data to prove problem exists

-align problem w/ Donabedian's Framework

-notify chain of command and gain approval for improvement team

-determine extent of problem

-consider financial aspects

-search literature for evidence-based improvements

-apply and test intervention

-develop sustainment plan

Donabedian's Framework

-framework for quality improvement based on structures -> process -> outcome -> structure

structure: how is care organized? stable elements

process: what is done? interactions b/w patients and providers

outcome: what happens to the patient's health? end result of interventions

benchmarking

process where an organization measures it's strategies, operations, or internal process performance against the best-in-class of industry, figures out how they do it so good, and using that to improve it's own performance

internal benchmarking

use of data from within the organization as comparison to benchmark

external benchmarking

use of data from other organizations

safety culture

outgrowth of organizational culture to emphasize deep assumptions and values towards safety

safety climate

shared perception of employees about the importance of safety within the organization

active error

-incident that is non-compliant w/ procedures

-example is not verifying patient ID before administering a medication

latent error

condition involves problems within the system; may lie dormant within the system for a long time; pose the greatest threat to safety in a complex system

misuse

avoidable complications that prevent patients from receiving full potential benefit of a service

overuse

potential for harm from the provision of a service that exceeds the possible benefit

adverse effect

injury resulting from medical intervention, not due to underlying condition

failure to rescue

failure to recognize or act on early signs of distress

work-arounds

when one does not follow the rules or process in order to save time or effort

near-miss

recognition that an event may have led to an adverse effect

sentinel event

event that resulted in immediate, permanent harm to a patient

root cause analysis

-in-depth analysis of an error to assess the event, ID causes, and solutions

-occurs after event has happened

failure mode and effect analysis

-proactive ID and risk reduction

-ideally prevents event from occurring

safe harbor act

-2007 statue in Nurse Practice Act in Texas

-invocation in good faith means RN believes that a requested conduct violates their duty to a patient BEFORE accepting the assignment (still will probably get the assignment)

characteristics of leaders

-may not have delegated authority but obtain power thru influence

-wide variety of roles

-may or may not be part of formal organizational hierarchy

-emphasize interpersonal relationships

-have goals that may/may not reflect those of organization

-direct willing followers

characteristics of managers

-assigned a specific duty and responsibilities by organization

-have legitimate source of power

-emphasize control, decision making/analysis

-manipulate people, money, time, and other resources to achieve organizational goals

-have greater formal responsibility and accountability

-direct willing and unwilling subordinates

leadership

-expressing a vision, establishing direction, aligning people to achieve the vision

-putting first things first

management

-planning, organizing, staffing, controlling complexity, and coordinating to bring order, consistency, and predictability to an organization

-disciplined output

leadership theories

-applied theory to better understand leadership

-types; behavioral, contingency, contemporary

behavioral theories of leadership

-theories proposing that specific behaviors differentiate leaders from nonleaders

-types; autocratic, democratic, laissez-faire

authoritarian leadership

-makes decisions for group, motivates by coercion, communication down the chain of command

-useful for employees w/ little to no formal education and for crisis situations

democratic leadership

-includes the group in decision making, motivates by supporting staff achievements, communication up and down chain of command

-work output of good quality when cooperating and collaborating

laissez-faire leadership

-little decision making and planning by leader, motivation is responsibility of individuals

-work output low unless informal leader emerges

-effective with professional employees

transactional leaders

-leaders who guide or motivate their followers in the direction of established goals by clarifying role and task requirements, maintaining the status quo

-motivate by rewards

transformational leaders

empower and inspire followers to achieve common vision

laissez-faire leaders

permissive and encourage group decision making

bureaucratic leaders

-aka authentic

-inspire followers by modeling strong moral code

situational leaders

flexible, adapt style to fit team and situation

contingency theories of leadership

-account for factors beyond the leader (leadership style contingent upon these extra factors instead of applying to all)

-Fiedler's Contingency Theory, Hersey-Blanchard Situational Theory, Path Goal theory, substitutes for leadership

Fielder's Contingency Theory

-success of leader depends on attaining proper match b/w leadership style and situational variables

situational variables per Fielder's Contingency Theory

leader-member relations, task structure, leader's position power

Hersey-Blanchard Situational Theory

-effective leadership dependent on matching leadership style to follower maturity

-variables are task behavior, relationship behavior, and level of maturity

path goal theory

-leadership theory that states that leaders can increase subordinate satisfaction and performance by clarifying and clearing the paths to goals and by increasing the number and kinds of rewards available for goal attainment

-styles; directive, supportive, participative, achievement oriented

substitutes for leadership

-factors in the workplace that can exert the same influence on employees as leaders would provide

-substitutes make leaders redundant

-neutralizers interfere with leader's actions

contemporary theories of leadership

charismatic theory, transformational theory, servant leadership, knowledge workers

charismatic theory of leadership

-focus on personal relationships b/w leaders and followers

-leadership traits; articulate clear vision based on values, models values based on said vision, communicate high expectations, and support follower's abilities

ethical vs unethical charismatics

ethical; provide developmental opportunities, get positive and negative feedback, recognize the work of others, share info

unethical; control and manipulate followers, act in self interest, only get positive feedback

transformational theory of leadership

theory that causes changes to individuals and social systems

servant leadership

-style that focuses on improving the lives of the followers and the integrity of the organization

management theories

scientific, bureaucratic, human relations

scientific management theories

-frontlined by Frederick Taylor

-belief that workers are motivated by $$ so wage based on quotas and productivity output

bureaucratic management theory

-Max Weber

-action taken on basis of written rules and regulations, advancement by standardized merit judged by the organization

human relations management theory

-theory that examines employees and work behavior as a complex network of interactions between and within individuals

-examines how social factors in the work environment influence employee work output

-belief that improving the work environment increases employee productivity

hawthorne effect

-the alteration of behavior by the subjects of a study due to their awareness of being observed

-attention on workers by management increases motivation and productivity

motivation theories

Maslow's Hierarchy, Hertzberg's Two Factor, McGregor's X and Y, Equity

Maslow's Hierarchy of Needs*

physiological, safety, love/belonging, esteem, self-actualization

Hertzberg's Two Factor motivation theory

-characteristics associated with dissatisfaction are different from those pertaining to satisfaction

-dissatisfaction by hygiene, satisfaction by motivation

McGregor's X and Y theory of motivation

Theory X - people innately dislike work and need an authoritarian management style

Theory Y- people enjoy work and can be trusted and empowered in their work

equity theory of management

-good workspace when one worker's input = output = other workers

-inequity when some people are working harder/less than others

informatics

use information and technology to communicate, manage knowledge, mitigate error, and support decision making

information system

integrated set of components like computers, software, and databases designed to collect, store, process, organize, and transfer data

data-information-knowledge-wisdom pyramid

bottom to top:

1) data

2) information

3) knowledge

4) action (wisdom)

illustrates progression from raw data to insight into the impact that data has on the world

TeamSTEPPS approaches to communication

SBAR for handoff

Two-Challenge for immediate cessation of actions to resolve a safety issue

CUS for immediate cessation of actions to resolve a safety issue

DESC Script for resolving conflict

DESC Script

constructive approach for managing and resolving conflict

Describe the specific situation or behavior; provide concrete data

Express how the situation makes you feel/what your concerns are

Suggest other alternatives and seek agreement

Consequences should be stated in terms of impact on established team goals; strive for consensus

CUS

I am Concerned

I am Uncomfortable

This is a Safety issue

Tuckman's Stages of Group Development

forming, storming, norming, performing, adjourning

forming

the first stage of team development, in which team members meet each other, form initial impressions, and begin to establish team norms

storming

the second stage of development, characterized by conflict and disagreement, in which team members disagree over what the team should do and how it should do it

norming

the third stage of team development, in which team members begin to settle into their roles, group cohesion grows, and positive team norms develop

performing

the fourth stage of team development, in which performance improves because the team has matured into an effective, fully functioning team

adjourning

the final stage of team development, where the team assesses performance, recognizes contributions, and plans for role transition

discipline

-training/molding a person to bring about desired changes

-is not the same as punishment

-progressive process

punishment

-undesirable event following unacceptable behavior

-used as threat/fear to control behavior

-not effective in long term; helps with rule compliance but not mission compliance and reduces long term productivity when used excessively

positive discipline

-helps employee grow, is supportive and corrective in nature

-must reassure employee that punishment is due to actions and not personal attack

destructive discipline

-Use of threats and fear to control behavior.

-Employee always alert to impending penalty or termination.

-Arbitrarily administered and either unfair in the application of rules or the resulting punishment.